Consenso latino-americano de hipertensão em pacientes com diabetes tipo 2 e síndrome metabólica

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Latin American consensus on hypertension in patientswith diabetes type 2 andmetabolic syndrome

Patricio Lopez-Jaramilloa, Ramiro A. Sanchezb, Margarita Diazc, Leonardo Cobosd, Alfonso Brycee,Jose Z. Parra Carrillof, Fernando Lizcanog, Fernando Lanash, Isaac Sinayi, Ivan D. Sierraj,Ernesto Penaherrerak, Mario Benderskyl, Helena Schmidm, Rodrigo Boteron, Manuel Urinao,Joffre Larap, Milton C. Fossq, Gustavo Marquezr, Stephen Harraps, Agustın J. Ramırezb,Alberto Zanchettit, on behalf of the Latin America Expert Group

The present document has been prepared by a group ofexperts, members of cardiology, endocrinology anddiabetes societies of Latin American countries, to serve asa guide to physicians taking care of patients with diabetes,hypertension and comorbidities or complications of bothconditions. Although the concept of ‘metabolic syndrome’is currently disputed, the higher prevalence in LatinAmerica of that cluster of metabolic alterations hassuggested that ‘metabolic syndrome’ is a usefulnosographic entity in the context of Latin Americanmedicine. Therefore, in the present document, particularattention is paid to this syndrome in order to alertphysicians on a particularly high-risk population, usuallyunderestimated and undertreated. These recommendationsresult from presentations and debates by discussion panelsduring a 2-day conference held in Bucaramanga, inOctober 2012, and all the participants have approved thefinal conclusions. The authors acknowledge that thepublication and diffusion of guidelines do not suffice toachieve the recommended changes in diagnostic ortherapeutic strategies, and plan suitable interventionsovercoming knowledge, attitude and behavioural barriers,preventing both physicians and patients from effectivelyadhering to guideline recommendations.

Keywords: arterial hypertension, diabetes, Latin Americanconsensus, metabolic syndrome

Abbreviations: ABPM, Twenty-four-hour ambulatoryblood pressure monitoring; ACCOMPLISH, AvoidingCardiovascular Events through Combination Therapy inPatients Living with Systolic Hypertension; ACCORD, Actionto Control Cardiovascular Risk in Diabetes Study; ACEI,angiotensin-converting enzyme inhibitors; ADA, AmericanDiabetes Association; ADVANCE, Action in diabetes andvascular disease# preterax and diamicron mr controlledevalution Study; ALTITUDE, Aliskiren Trial in Type 2Diabetes Using Cardio-Renal Endpoints; ARB, angiotensinreceptor blockers; ATP III, Adult Treatment Panel III; BP,blood pressure; CCB, calcium channel blockers; CHD,coronary heart disease; CI, confidence interval; CKD-EPI,Chronic Kidney Disease Epidemiology Collaboration; EMEA,European Medicines Agency; ESH-ESC, European Societyof Hypertension-European Society of Cardiology; ESRD,

end-stage renal disease; FDAU.S., US Food and DrugAdministration; GFR, glomerular filtration rate; Hb A1c,glycosylated haemoglobin; HIC, high-income countries;HOPE, Heart Outcomes Prevention Evaluation; HOT,Hypertension Optimal Treatment Study; IDF, InternationalDiabetes Federation; IFG, impaired fasting glucose; IGTT,impaired glucose tolerance test; LIC, low-income countries;MDRD, Modification of Diet in Renal Disease; OGTT, oralglucose tolerance test; ONTARGET, Ongoing TelmisartanAlone and in Combination with Ramipril Global EndpointTrial; PAHO, Pan American Health Organization; PURE,Prospective Urban Rural Epidemiology study; RAAS, renin–angiotensin–aldosterone system; UAE, urinary albuminexcretion; UKPDS, United Kingdom Prospective DiabetesStudy; UMIC & LMIC, upper middle and low middleincome; VO2 max, aerobic capacity; WHO-ISH, WHO-International Society of Hypertension

Journal of Hypertension 2013, 31:223–238aFundacion Oftalmologica de Santander FOSCAL, Universidad de Santander UDES,Bucaramanga, Colombia, bArterial Hypertension and Metabolic Unit, HospitalUniversitario, Fundacion Favaloro, Buenos Aires, Argentina, cClınica Platinum,Montevideo, Uruguay, dColegio Panamericano del Endotelio, Santiago, Chile,eClınica del Golf, Lima, Peru, fUniversidad de Guadalajara, Guadalajara, Mexico,gAsociacion Colombiana de Endocrinologıa, Universidad de La Sabana, Bogota,Colombia, hUniversidad de la Frontera, Temuco, Chile, iInstituto Cardiologico deBuenos Aires, Buenos Aires, Argentina, jAsociacion Latinoamericana de Diabetes,Bogota, Colombia, kHospital Luis Vernaza, Guayaquil, Ecuador, lUniversidad deCordoba, Cordoba, Argentina, mUniversidad Federal do Rio Grande do Sul, PortoAlegre, Brazil, nCentro Medico, Medellin, Colombia, oSociedad Colombiana deCardiologıa, Bogota, Colombia, pSociedad Ecuatoriana de Aterosclerosis, Guayaquil,Ecuador, qUniversidad de Sao Paulo, Ribeirao Preto, Brazil, rFederation DiabetologicaColombiana, Corozal, Colombia, sUniversity of Melbourne, Melbourne, Australia andtIstituto Auxologico Italiano, Milan, Italy

Correspondence to Patricio Lopez-Jaramillo, MD, Clınica de Sındrome Metabolico,Prediabetes y Diabetes, Departamento de Investigacion, Fundacion Oftalmologica deSantander (FOSCAL), Facultad de Medicina, Universidad de Santander (UDES), Calle155 A No. 23-09, Floridablanca, Santander, SA, Colombia. E-mail [email protected]

Received 6 November 2012 Accepted 6 November 2012

J Hypertens 31:223–238 ! 2013 Wolters Kluwer Health | Lippincott Williams &Wilkins.

DOI:10.1097/HJH.0b013e32835c5444

Journal of Hypertension www.jhypertension.com 223

Guidelines

mailto:[email protected]


INTRODUCTION

H ypertension, diabetes and that cluster of metabolicalterations often referred to as the metabolic syn-drome are highly prevalent in Latin America and

occur frequently as associated conditions. The develop-ment of diagnostic and therapeutic recommendations pre-pared through the joint work of experts in different areas ofmedicine is desirable, considering the low rates of controlachieved in the real world, and the benefits that can beexpected when reasonable objectives are met. Healthcareresources and priorities, the socioeconomic status of thepopulation and the prevalence of hypertension, diabetesmellitus and other related diseases vary considerably indifferent regions of the world and also in different countrieswithin each region, and even in different areas of individualcountries. Recommendations to be usefully translated intopractice should consider the particular medical and socialfeatures of the region where they should be applied and becost-effective in terms of local needs and possibilities. Forthese reasons, the WHO-International Society of Hyperten-sion (WHO-ISH) [1] and European Society of Hypertension-European Society of Cardiology (ESH-ESC) [2] documentshave encouraged the development of regional guidelines.Furthermore, acceptance and usage are likely to be greater iflocal physicians and experts are involved in their develop-ment and subsequent diffusion and implementation [3,4].

That is why this document has been prepared by a groupof experts, members of cardiology, endocrinology anddiabetes societies of Latin American countries, to serve asa guide to physicians taking care of patients with diabetes,hypertension and comorbidities or complications of bothconditions. Although the concept of ‘metabolic syndrome’is currently disputed, the higher prevalence in LatinAmerica of that cluster of metabolic alterations hassuggested that ‘metabolic syndrome’ is a useful noso-graphic entity in the context of Latin American medicine.Therefore, in the present document, particular attention ispaid to this syndrome in order to alert physicians on aparticularly high-risk population, usually underestimatedand undertreated.

These recommendations result from presentations anddebates by discussion panels during a 2-day conferenceheld in Bucaramanga, in October 2012. Chairs andmoderators of the plenary session were Dr Stephen Harrapand Dr Alberto Zanchetti, and all the participants haveapproved the final conclusions.

The authors acknowledge that the publication anddiffusion of guidelines do not suffice to achieve the recom-mended changes in diagnostic or therapeutic strategies,and plan suitable interventions overcoming knowledge,attitude and behavioural barriers preventing both physi-cians and patients from effectively adhering to guidelinerecommendations [5,6].

A great diversity in socioeconomic characteristics isfound in Latin American countries, and this is reflected indifferences in cardiovascular mortality and morbidity. Atvariance with what has occurred in the United States andWestern Europe, in most Latin American countries, cardio-vascular mortality rate has increased during the last decadesof the twentieth century and the beginning of the twenty-

first century, with the exception of Argentina and Uruguay.Even in the latter countries, however, cardiovascular mor-bidity and prevalence of cardiovascular risk factors havepersisted unchanged or have increased, what has particu-larly occurred for arterial hypertension, obesity, metabolicsyndrome and diabetes [7,8]. Indeed, years before thecurrent increase of cardiovascular illness, lifestyle changeshave appeared in the region with changes away fromtraditional alimentary habits and access to westernizedmodels of nutrition that are likely to have facilitated thegenetic expression of these diseases [9]. The pattern ofmorbidity is further complicated by the phenomenon ofa progressive migration of rural inhabitants to urban areas,which increases the urban periphery with low resourceindividuals, favouring emergent risk factors as accultura-tion, violence, stress and malnutrition [7].

PREVALENCEOFARTERIALHYPERTENSION IN LATINAMERICACardiovascular risk factors are defined as biological charac-teristics or lifestyles increasing the probability (risk) ofcardiovascular morbidity and mortality [10]. As a cardiovas-cular risk factor, hypertension usually integrates a cluster ofrisk factors defined, operationally, as the metabolic syn-drome. Among these risk factors, arterial hypertensionranks as the first cause of mortality worldwide, and thethird cause of illness-induced disability after malnutritionand risky sex [11].

Table 1 shows prevalence, awareness, treatment andcontrol of arterial hypertension in Latin America. Preva-lence of hypertension [12–14] was similar in Argentina(25–36%), Uruguay (30%), Paraguay (21–30%) and thesouth of Brazil (31–33%). In Chile [15], differences werefound depending on socioeconomic level (lower: 24.5%,higher 17.9%). Differences depending on the living areaswere observed in Mexico, when urban (30%) or rural areas(11.7%) were compared [16]. A recent study [17 and Chowet al. in preparation], the Prospective Urban Rural Epidemi-ology (PURE) study, included 153 996 adults (35–70 years)from 628 rural and urban communities from three high-income countries (HICs), 10 upper middle and low middleincome (UMIC and LMIC) and four low-income countries(LIC) in various parts of the world. Hypertension wasdefined when individuals reported treatment for hyperten-sion or had an average blood pressure (BP) greater than140/90 mmHg from two measures of resting sitting BP usingan automated digital device. Overall, 40.7% of participantswere found to have hypertension, with 13.3% having a BPof at least 160/100mmHg and 4.4% a BP of at least 180/110 mmHg. Of those with hypertension, 46.4% were awareof this condition, 40.6% were on pharmacological treat-ment, but only 13.1% had BP controlled (<140/90 mmHg).The prevalence of hypertension was similar in UMIC(49.6%), HIC (40.7%) and LMIC (39.6%), but lowest inLIC (32.2%). The percentages of awareness (HIC: 49.1%,UMIC: 52.4%, LMIC: 43.5% and LIC: 40.8%;trend!P< 0.001), treatment (46.8, 48.3, 36.8 and 31.7%,respectively; trend!P< 0.001) and controlled (19, 15.5, 9.9and 12.7%, respectively; trend!P< 0.001) were inverselyrelated to the economic level of the country. Prevalence,

Lopez-Jaramillo et al.

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awareness, treatment and control were higher in urban thanin rural communities in LIC and in LMIC, but this did notoccur in HIC and UMIC. Overall, 12.5% of treated hyper-tensive patients received two or more BP lowering medi-cations, with a decreasing trend from wealthier to poorercountries (HIC, 18.1%, UMIC 14.5%, LMIC 14.1%, LIC 1.6%;P< 0.0001). Lower level of education was strongly associ-ated with lower rates of awareness, treatment and controlin countries of lower economic status, but this was lessevident in other countries. Hypertension prevalence washighest in participants with diabetes (63%), and eventhough awareness was 74.4%, and the percentage of thosewho received treatment 69.3%, the control rate was only23.3%. Analysis by region indicated that prevalence ofhypertension was highest in Africa (56.6%), followed byMalaysia (46.5%) and South America (46.5%). The SouthAmerican countries included in the PURE study wereArgentina, Brazil, Chile and Colombia. Table 2 shows thecharacteristics of the individuals studied by country. Aware-ness, treatment and control of hypertension in the fourSouth America countries averaged 57.0, 52.8 and 18.3%,respectively [Chow et al. in preparation].

From the data reviewed, it can be concluded that, all overthe world, hypertension detection and treatment are poor,and that even the majority of the patients being treatedhave poor BP control. These findings were common toall countries with different economic levels, although

treatment and control were markedly worse in LIC. Thus,systematic efforts for community-wide screening andimplementation of simple algorithm based strategies arecrucial to reduce the burdenof hypertension-related disease.

PREVALENCEOF METABOLICSYNDROME IN LATINAMERICAIn Latin America the prevalence of metabolic syndromecomponents, including arterial hypertension, appears tobe increasing. A large body of local studies [18–41] hasreported that the prevalence in adults range from 25 to 45%,with important differences between urban and rural areas,but comparisons are difficult because different definitionsof metabolic syndrome were used. In patients withmyocardial infarction or stroke [27], the prevalence wasas high as 75%, regardless of the diagnosed criteria used(International Diabetes Federation, IDF, or Adult TreatmentPanel III, ATP III.). In a recent meta-analysis, whichincluded 12 cross-sectional studies in Latin Americancountries [42], the general prevalence (weighted mean)of metabolic syndrome using the ATP III criteria was24.9% (range: 18.8–43.3%). The metabolic syndrome wasslightly more frequent in women (25.3%) than in men(23.2%), and the age group with the highest prevalencewas that over 50 years. The most frequent components ofmetabolic syndrome were low high-density lipoprotein

TABLE 1. Awareness, treatment and control rates of arterial hypertension in Latin America

Country PlaceYear of

publicationAge

(years)Total

numberHypertensivepatients (%) % Awareness % Treated % Controlled

Argentina La Plata 1988–1989 15–75 6386 32.3 44.0 (42.8–45.2) 33.1 (31.0–35.2) 5.0 (4.3–5.4)

Rauch 1992 15–75 1523 35.7 36.5 (35.5–37.5) 32.7 (31.1–32.9) 4.0 (2.6–6.0)

Lujan 1995 18–79 2475 24.6 56.9 (55.7–58.1) 54.2 (53.0–55.4) 23.0 (22.0–24.0)

Cordoba 1999 15–85 6875 29.9 54.9 (52.4–57.4) 43.0 (40.5–45.5) 13.0 (11.3–14.8)

Dean Funes 1999 20–70 750 29.7 19.3 (14.4–25.1) 6.7 (3.8–10.8) –

Rosario 1999 21–65 2071 31.3 79.7 (78.1–81.3) 47.8 (45.8–49.8) 25.3 (23.3–26.8)

Rural/Urban NP 19–99 10415 26.0 50.8 (48.6–53.0) 41.7 (39.6–43.8) 13.0 (11.3–14.8)

Buenos Aires 2005 25–64 1482 29.0 64.1 (59.9–68.2) 41.6 (37.5–45.8) 18.0 (14.8–21.2)

Brazil Porto Alegre 1994 >18 1091 29.7 39.1 (33.7–44.6) 13.8 (10.3–18.1) –

Sao Paulo (NE) 2001 >18 688 31.5 77.0 (70.7–82.4) 61.8 (54.9–68.3) 17.0 (12.3–22.7)

Colombia Bogota 2005 25–64 1553 13.5 68.8 (62.5–75.5) 55.0 (48.2–61.8) 30.6 (25.8–35.5)

Chile Concepcion 1988 >14 10139 18.6 65.7 (63.5–67.8 30.0 (27.9–32.2) 7.5 (6.4–8.7)

Concepcion 2004 >15 8472 21.6 66.6 (NR) 59.9 (NR) 30.7 (NR)

Valparaıso 1999 25–69 3120 11.0 44.0 (42.2–45.8) 22.0 (20.5–23.5) –

Santiago 2005 25–69 1655 23.8 61.1 (55.4–64.7) 43.0 (38.8–47.7) 20.3 (16.4–24.2)

Cuba National NR NR 102235 39.7 70.2 (NR) – 39.7 (39.2–40.2)

Ecuador National 1999 >18 10605 28.6 41.0 (37.7–43.4) 23.0 (22.3–23.8) 7.0 (6.5–7.5)

Quito 2005 25–64 1638 8.6 67.6 (60.2–74.9) 51.8 (43.9–59.8) 28.0 (19.9–36.1)

Mexico Guadalajara 1980 >16 4031 21.5 51.3 (47.9–54.7) 45.6 (42.3–49.1) 7.6 (6.0–9.6)

Aguas Calientes 1997 >25 6128 26.8 75.0 (73.9–76.1) 37.0 (35.8–39.2) –

Durango 1998 >20 5802 21.9 69.1 (67.9–70.3) – –

North (Rural) 2000 25–64 815 6.8 41.0 (37.5–44.5) – –

National 2000 25–64 38377 31.3 43.0 (42.1–43.9) 20.3 (17.9–22.9) 4.9 (3.7–6.3)

Mexico DF 2005 25–64 1722 11.6 75.7 (70.1–81.2) 65.7 (60.4–70.9) 41.0 (36.2–45.8)

Paraguay National 1995 18–74 9880 30.4 11.0 (10.4–11.7) 5.5 (5.1–6.0) 0.0

Peru Lima 2005 25–64 1652 12.5 53.1 (46.5–59.6) 28.8 (24.0–33.5) 12.0 (8.4–15.7)

Uruguay Minas NR >18 560 37.3 78.5 (72.2–83.9) 47.4 (40.4–54.3) 16.3 (11.5–22.0)

Venezuela Barquisimeto 1994 >20 15000 23.5 61.3 (60.5–62.1) 46.0 (44.4–47.6) 20.6 (19.2–22.0)

Barquisimeto 2000 #20 7424 36.8 45.7 (44.7–46.8) 22.9 (21.9–23.9) 4.5 (4.0–5.0)

Maracaibo 2005 25–64 1848 24.6 72.0 (67.8–76.2) 48.9 (44.2–53.5) 20.7 (17.4–24)

Awareness, treated and controlled refers to patients who are aware of arterial hypertension, under treatment and reached values $140/90 mmHg. Data, in these cases, are given aspercentual of the hypertensive population (95% CI). CI, confidence interval; NR, not referred.

Latin American consensus on hypertension diabetes



(HDL)-cholesterol levels (62.9%) and abdominal obesity(45.8%). Similar findings were reported in the multicentreCARMELA study on Latin American cities [21].

PREVALENCEOF DIABETES TYPE 2 INLATINAMERICAIn the Latin American urban population, the prevalence ofdiabetes is between 4 and 8%, being higher in countries orareas with a lower or medium socioeconomic level (Table3). However, data are scanty and the percentage of patientswithout confirmation of the diagnosis is around 30–50%and can be higher in rural areas. The CARMELA study [12]conducted in seven Latin American cities during 2005 foundthat the prevalence of diabetes had almost doubled fromvalues previously reported. Diabetes prevalence was 6.0%in Barquisimeto (Venezuela), 8.0% in Bogota (Colombia),6.2% in Buenos Aires (Argentina), 8.9% in Mexico and 7.2%in Santiago (Chile). As in other areas of the world, thegrowing prevalence of diabetes in Latin America is due,mainly, to changes in lifestyle: lower physical activity,higher caloric intake and increased prevalence of over-weight/obesity as well as urbanization.

In diabetic populations, the prevalence of arterial hy-pertension is 1.5–3 times higher than in nondiabetic indi-viduals with similar age, with a particularly high associationin medium and low-income countries [12,43–48].

PREVALENCEOFOVERWEIGHTANDOBESITY IN LATINAMERICAThe important proportion of individuals with overweight(BMI 25–29.9 kg/m2) and obesity (BMI #30 kg/m2) can be

appreciated in different surveys in Latin America [44–61].In Rosario, Argentina [48], the prevalence of overweightwas 40% and that of obesity 29%. In the city of Rio deJaneiro [55], overweight was present in 40% and obesity in21% of the population studied. In Mexico [43,49], theoverweight prevalence ranged from 37% in rural areas to48% in Mexico DF, and obesity was around 21% (rural: 7%,DF: 29%). In Cuba [54], overweight and obesity togetherwere around 22%. In many studies, obesity and arterialhypertension were strongly associated with a proportion of40% of individuals with both arterial hypertension andobesity.

Estimates of the specific prevalence of obesity haveshown a great variability among Latin American popu-lations, ranging from 9.9 to 35.7% [57]. Women[23,33,37,51] and individuals living in urban areas [41] havebeen identified as the groups predominantly affected. Inaddition, obesity has been independently associated withlow socioeconomic status and poorer educational level[49,53], thus contributing to health inequalities in the region[59,60]. However, there is evidence of a secular trendtowards an increase in obesity prevalence in the mosteconomically developed Latin American countries [61].

As with adults, obesity has also become a health problemwith children in Latin America, because a high risk ofobesity persistence in adult age is associated with develop-ment of arterial hypertension [22,50,51].

METABOLIC SYNDROME, DIABETES ANDHYPERTENSION: DEFINITION,DIAGNOSIS AND CLINICAL EVALUATIONMetabolic syndromeAs mentioned above, the concept of metabolic syndrome isdisputed mostly because it is hard to prove that the syn-drome cardiovascular risk is higher than that attributable tothe sum of the risks attributed to each of its component.However, metabolic syndrome is a clinical pattern witheasily detectable features, yet largely under-detected, andindicates, under a simple term, a cluster of metabolicalterations highly prevalent in Latin America. Thus, it is auseful instrument to identify individuals at a higher risk ofcardiovascular disease (CVD) as well as of diabetes. It iscommonly accepted that all components of metabolic syn-drome are associated with insulin resistance [26,62,63].

The recent consensus of the International DiabetesFederation Task Force on Epidemiology and Pre-vention, the National Heart, Lung, and Blood Institute,the American Heart Association, the World Heart

TABLE 2. Characteristics of South America participants by country

Country NumberRecruited

(years)Rural

[n! (%)]Female

[n! (%)]Age

(years, SD)SBP

(mmHg, SD)DBP

(mmHg, SD)

BP #140/90 mmHg[n! (%)]

BP #160/100 mmHg[n! (%)]

Argentina 7483 2006–2009 3894 (52.0) 4603 (61.5) 51 (10.0) 135.6 (21.7) 82.75 (12.5) 3804 (50.8) 2455 (32.6)

Brasil 5566 2005–2009 1300 (23.4) 3076 (55.3) 52 (9.4) 132.33 (23.8) 86.63 (38.0) 2928 (52.6) 2274 (37.5)

Chile 3212 2006–2009 643 (20.0) 2135 (66.5) 52 (9.8) 130.80 (22.2) 82.11 (20.4) 1499 (46.7) 1058 (30.7)

Colombia 7417 2005–2009 3964 (53.4) 4759 (64.2) 51 (9.7) 128.77 (23.3) 81.05 (16.9) 2781 (37.5) 1737 (23.3)

BP #140/90 mmHg: self-reported hypertension or values #140/90 mmHg; BP #160/100 mmHg: self-reported hypertension or values #160/100 mmHg. BP, blood pressure. Adapted fromChow et al. in preparation.

TABLE 3. Prevalence of diabetes mellitus in Latin America

Country %

Argentina 5.0a

Bolivia 7.2b

Brasil 7.6c

Colombia 7.3b

Cuba 4.5

Chile 3.9b

Jamaica 13.4a

Mexico 8.6b

Paraguay 6.2b

Uruguay 7.0b

Venezuela 4.4b

%! Population studies published until 2010.aWHO 1980.bWHO 1985.cADA-WHO 1997.




Federation, the International Atherosclerosis Societyand the International Association for the Study of Obesity[62] has proposed that the presence of three of the fivefollowing criteria make the diagnosis of metabolic syn-drome:

(1) Elevated waist circumference, the definition ofwhich is population and country specific;

(2) Elevated triglycerides at least 150 mg/dl, or drugtreatment for elevated triglycerides;

(3) Reduced HDL-cholesterol less than 40mg/dl in menand less than 50mg/dl in women. (Drug treatmentfor reduced HDL-cholesterol is an alternativeindicator, such as nicotinic acid);

(4) BP in the high-normal or hypertensive range (SBP#130 mmHg and/or DBP #85mmHg or currentantihypertensive drug treatment); and

(5) Elevated fasting glucose at least 100 mg/dl or drugtreatment for elevated glucose plasma levels.

Several authors consider that central (abdominal)obesity is the main factor in metabolic syndrome andshould be included in the diagnosis. To define abdominalobesity in Latin America, a recent study [64], which hasincluded capital cities of various countries, has recom-mended cut-off values of waist circumference of 94 cmfor men and 88 cm for women. However, a number ofindependent studies have indicated that the cut-off pointssuggested by the IDF (90 cm for men and 80 cm for women)are better related with the presence of the other com-ponents of the metabolic syndrome in the Latin Americanpopulation [27,28,30,34,36]. Although no cohort studies areavailable in Latin America evaluating the relation of waistcircumference cut-off points with future development ofdiabetes or CVD, it is expected that, as with most riskfactors, the relation is continuous, and any cut-off is basedon arbitrary conventions. The choice of the authors of thisconsensus document is to use the IDF cut-off values. Therisk factors that are associated with a higher risk of meta-bolic syndrome are listed as follows:

(1) Family history of type 2 diabetes mellitus;(2) Gestational diabetes mellitus;(3) Macrosomy(4) Low birth weight(5) Childhood undernutrition(6) High perinatal mortality and/or early CVD in first-

order relatives;(7) Sedentary habit;(8) Diet rich in animal fat;(9) Ethnicity;

(10) Low socioeconomic status;(11) History of dislipidemia, obesity and hypertension;(12) Hyperandrogenism in women; and(13) Achantosis nigricans.

The diagnosis of metabolic syndrome may be helpfulin primary prevention of diabetes mellitus, hypertensionand CVD. Detection is expected to increase awareness ofcardiometabolic risk in both physicians and patients andconsequently to reinforce motivation, for adequate changes

in lifestyle and weight reduction. Evidence for drug treat-ment is lacking, but when BP and plasma glucose are abovethe accepted threshold defining hypertension and, respect-ively, diabetes, antihypertensive and antidiabetic treat-ments should be initiated.

Type 2 diabetesThe criteria for diagnosis of type 2 diabetes mellitus,adopted and recommended by the Latin American Con-sensus, are listed as follows:

(1) Fasting glucose at least 126 mg/dl in two successivereadings

(2) At least 200 mg/dl 120 min after oral glucosetolerance test

(3) At least 200 mg/dl at any time in the presenceof symptoms

The American Diabetes Association (ADA) criteria fordiabetes diagnosis [65] were adopted, but the importance ofthe oral glucose tolerance test (OGTT) as a more specificdiagnostic tool was considered. The recently revived term‘prediabetes’, and a lower threshold for glucose intolerance[an impaired fasting glucose (IFG: 100–125 mg/dl) and/orimpaired glucose tolerance test (IGTT: 140–199 mg/dl)]may improve diabetes detection [66,67], but cost-effective-ness of this strategy in terms of treatment implementationand prevention of complications is yet unknown [68], andtherefore, the ADA classification has been preferred [65].

Hypertension: classification and diagnosisAfter considering the classifications proposed by theSeventh Report of the Joint National Committee on Pre-vention, Detection, Evaluation, and Treatment of HighBlood Pressure [69], the 2007 ESH-ESC guidelines onhypertension management [70], the 2009 Reappraisalof the European guidelines [71] and the previous LatinAmerican Consensus on Arterial Hypertension [10], it wasdecided, as shown in Table 4, to maintain the concept thathypertension is diagnosed when BP values are at least 140or 90mmHg in the physician’s office or health clinic. Abovethis value, hypertension can be subdivided in grade 1, 2 or3. This classification also applies to isolated systolic hyper-tension, which must be diagnosed and treated especiallyin older patients. Elderly patients aged over 80 yearsshould be diagnosed as hypertensive when BP is at least150/90 mmHg. In elderly patients, BP should also bemeasured in the upright position to detect a possibleexcessive orthostatic decline.

TABLE 4. Classification of blood pressure and hypertensionrecommended by the Latin American Consensus

Blood pressure Value (mmHg)

Optimal <120/80

Normal 120/80–129/84

High normal 130/85–139/89

Grade 1 hypertension 140/90–159/99

Grade 2 hypertension 160/100–179/109

Grade 3 hypertension #180/110

Isolated systolic hypertension #140/<90




Arterial hypertension is actually classified as primary,essential or idiopathic, when BP is consistently higher thannormal with no known underlying cause. It represents over90% of all cases of hypertension. Hypertension is defined assecondary, when BP is elevated as a result of an underlying,identifiable and often correctable cause (the remaining 10%of the hypertensive patients).

Diagnosis of hypertension should be based on at leastthree different BP measurements, taken on, at least, twoseparate office or clinic visits. Arterial hypertensionshould be diagnosed when BP is at least 140 and/or90 mmHg. Although office or clinic values are those uponwhich diagnosis and treatment should be usually based,there are additional methods of BP measurement that areuseful in several cases. Twenty-four-hour ambulatory BPmonitoring (ABPM) is more closely related to prognosisthan office BP [72,73], and two subgroups of hypertensivepatients can be detected, when office and ambulatory BPare found divergent: white-coat hypertensive patients(office hypertension and ambulatory normotension)and masked hypertensive patients (office normotensionalong with ambulatory hypertension). Upper cut-offvalues for hypertension diagnosis by ABPM are indicatedin Table 5.

There are clinical situations in which ABPM may behelpful for the diagnosis of hypertension, for examplewhen white-coat hypertension is suspected, whenpatients with marked hypertension have no signs oftarget organ damage and when there are marked differ-ences in BP values measured at different visits. There arealso indications for home BP measurements, which areknown to increase treatment compliance. Only validatedautomatic devices should be used, and the patientinstructed to do the measurements in the seated position,after several minutes of rest, ideally both in the morningand evening. During treatment, measurements should be

done before antihypertensive drugs are taken in themorning.

To manage a hypertensive patient, not only BP levelsshould be considered but also total cardiovascular risk. Inorder to stratify total cardiovascular risk, the number ofcardiovascular risk factors, the absence or presence oftarget organ damage and of previous or concurrent clinicalconditions or outcomes, including the metabolic syndromeand diabetes, should be taken into account together withBP grading, as summarized in Table 6.

Hypertension in patients with diabetesAs a result of impaired autonomic function and extensiveorgan damage, higher BP variability, marked orthostaticresponses and impaired nocturnal BP reductions are com-mon features in diabetic individuals [72]. These featureshave diagnostic, prognostic and therapeutic implications:the number of BP measurements for decision-makingshould be higher, detection of orthostatic hypotensionshould be a routine procedure, and home and, especially,ambulatory BP measurements are strongly recommendedin diabetic individuals, whenever possible. Updated infor-mation on this topic is available [73], and training in theinterpretation of data is advisable.

Recommendations on diagnostic evaluation in patientswith hypertension and diabetes are summarized in Table 7.The diagnostic follow-up recommendations are listed asfollows:

(1) HbA1c (every 4 months)(2) Blood glucose self-monitoring (every 24–48 h)(3) Yearly: fundus, ECG, microalbuminuria, basic

laboratory tests(4) Every 2 years: echocardiogram and ECG stress test

(possible silent ischemia)

TABLE 5. Hypertension, blood pressure criteria

Hypertension Office or clinic blood pressure #140/90 mmHg (average ofthree measurements/visit, three visits)

24-h ABP #130/80 mmHg, daytime ABP #135/85 mmHg

Home or self-measurement BP #135/85 mmHg

White-coat hypertension Office or clinic hypertension and home or ambulatory normotension

Masked hypertension Office or clinic normotension with home or ambulatory hypertension

ABP, ambulatory blood pressure.

TABLE 6. Risk stratification in patients with metabolic syndrome, hypertension and diabetes type 2

Normotension Hypertension

Other riskfactors or diseases Optimal Normal High normal Grade 1 Grade 2 Grade 3

No RF Mean risk Mean risk Mean risk Low added risk Moderateadded risk

High addedrisk

1–2 RF or socialconditions of risk

Low added risk Low added risk Low added risk Moderateadded risk

Moderateadded risk

Very highadded risk

#3 RFs or socialconditions of risk,TOD or MS/DM

Moderateadded risk

Moderateadded risk

High added risk High added risk High added risk Very highadded risk

Clinical-associatedcondition

High added risk High added risk Very highadded risk

Very high added risk Very highadded risk

Very highadded risk

DM, diabetes mellitus; MS, metabolic syndrome; RF, risk factor; TOD, target organ damage.




In terms of total cardiovascular risk (see Table 6),the presence of diabetes is usually considered to imply ahigh level of risk, but it is reasonable to believe thatcardiovascular risk is different in recent or long-term dia-betes, in absence or in presence of complications. Innormotensive patients with diabetes, there is no evidencethat BP-lowering drugs are of any benefit.

RENAL AND CARDIOVASCULARCOMPLICATIONS IN DIABETICHYPERTENSIVE PATIENTSPatients with diabetes and hypertension are at an increasedrisk of renal disease, coronary heart disease (CHD), strokeand heart failure. The association with comorbidities suchas dyslipidemia, prothrombotic state and autonomic dys-function [74] contributes to an increase in morbidityand mortality.

Diabetic nephropathyThe prevalence of nephropathy in patients with type 2diabetes is 30–50% [75]. Three stages are described [76],which are reported as follows:

(1) Incipient nephropathy, lasting about 10 years withsupranormal glomerular filtration rate (GFR),accompanied after about 5 years by increasedurinary albumin excretion (UAE: 30–300 mg/dayfor microalbuminuria). The presence of increasedUAE identifies diabetic patients at a higher riskof developing progressive kidney damage andCVD.

(2) Clinical evident nephropathy, characterized by aUAE over 300 mg/day (overt proteinuria), a normalor moderately reduced GFR and hypertension. Ifuntreated, these patients are at a high risk of pro-gressing to end-stage renal disease (ESRD). Withoutintervention, this condition may progress faster, and50% of patients could reach ESRD in 10 years and75% in 20 years. Conversely, therapeutic interven-tions in both types of diabetes slow the rate of GFRdecline. It has been reported that 20–40% of indi-viduals with UAE could progress to macroalbumi-nuria and 20% of them to ESRD.

(3) Progressive renal insufficiency with overt proteinu-ria (300mg/day) and a markedly reduced GFR(<30ml/min). Macroalbuminuria identifies diabetic

patients with substantial histological kidney damageand predicts a linear decline in GFR.

For screening the onset and progression of diabeticnephropathy, it is mandatory to test UAE every year atthe onset of diabetes 2 and to estimate GFR from serumcreatinine by using one of the current validated formulae[Modification of Diet in Renal Disease (MDRD) or ChronicKidney Disease Epidemiology Collaboration (CKD-EPI)].

Coronary heart diseaseType 2 diabetic patients with hypertension have a 1.9 timeshigher risk of CVD than hypertensive patients withoutdiabetes [77]. Factors such as elevated fibrinogen levels,particularly during poor glycaemic control, elevated levelsof plasminogen activator inhibitor-1 and increased plateletaggregation may be responsible [78]. These diabetes-relatedalterations may increase the risk of thrombosis at the site ofplaque disruption and also the risk of reinfarction afterthrombolytic therapy or revascularization. Furthermore,cardiac arrhythmias are frequently seen as a consequenceof the autonomic dysfunction. Evaluation of CHD shouldinclude an exercise stress test followed, if positive, by amyocardial perfusion study (Single-photon emission com-puted tomography).

Left ventricular dysfunction and heart failureDiabetes is a major risk factor for left ventricular dysfunc-tion and heart failure. In the Glasgow Monica study, theincidence of left ventricular dysfunction was higher indiabetic patients (29%) than in nondiabetic individuals(7%) [79]. In the Framingham Study, relative risks for clinicalheart failure were 3.8 in men and 5.5 in women withdiabetes compared with those without diabetes [80]. Indiabetic patients with glycosylated haemoglobin (HbA1c)less than 7.0% the rate of heart failure was 4.2 per 1000patient years, and this rate increased to 9.2 per 1000 patientsyearly when HbA1c was over 10% [80]. The poor prognosisof these patients has been explained by an underlyingdiabetic cardiomyopathy exacerbated by hypertensionand ischaemic heart disease [81].

The high prevalence and significant morbidity andmortality of heart failure dictate early identification of riskfactors and clinical signs. A careful history may help indetection of symptoms of heart failure (dyspnoea on effort,orthopnoea, nocturnal cough and easy fatigability),although patients with left ventricular systolic dysfunctionmay not report symptoms [82]. Therefore, the diagnosis of

TABLE 7. Recommended diagnostic evaluation of hypertensive patients with diabetes mellitus

Basic or minimal investigations Clinical history and physical examination

Blood pressure measurement (according to AHA)

ECG

Laboratory tests: fasting glucose and HbA1C, serum creatinine, lipid profile, liver enzymes, Na%, K%

Microalbuminuria (according to ADA)

Fundoscopy (when abnormal consult an ophthalmologist)

Optional investigations ABPM

ECG stress test (men >40 years, postmenopausal women)

Doppler echocardiogram

ABPM, ambulatory blood pressure monitoring; ADA, American Diabetes Association.




heart failure in the diabetic and hypertensive patient mayrequire further testing. Although an electrocardiogramand a radiograph may be helpful, Doppler echocardiog-raphy is needed to visualize the cardiac structural andfunctional changes underlying heart failure and is therecommended test whenever heart failure is suspected.As heart failure is a predictor of sudden cardiac death,24-h Holter ECG is recommended to screen for arrhyth-mias.

StrokeThe rates of stroke and stroke-related disability are higher indiabetic patients than in nondiabetic individuals [83]. Therisk of fatal versus nonfatal stroke is higher, the higherthe level of HbA1c even many years before the outcome[83–85].

TREATMENTOF HYPERTENSION INDIABETIC PATIENTSNonpharmacological treatment of hypertensionin diabetes mellitus

Dietary planCarbohydrates will account for 55–60% of the total caloriesintake (TCI), minimizing refined simple carbohydrates(sugar, honey, fructose, molasses, and so on), whileincreasing complex carbohydrates (vegetables, fruits andwhole grains). The use of noncaloric sweeteners is allowed,but those with low sodium content should be selected.

Proteins will account for 0.8–1 g/kg of ideal bodyweight. Animal proteins are to be preferred due to theirhigh biological value, but legumes and cereals should beincluded to add proteins and fibre.

Fibre should be taken approximately 30 g/day, prefera-bly soluble fibre.

Fat will account for no more than 30% of the TCI, withsaturated (dairy fat and by-products) 10% or less, polyun-saturated (vegetable oils, dried fruits, fish) 10% and mono-unsaturated (avocado, olives, chicken, pork) greater than10%.

Vitamins and trace elements should be taken as recom-mended for the general population.

Minerals should include sodium 2–3 g (4–6 g sodiumchloride), and convenience foods should be avoided. It isadvisable to know the sodium content of drinking water inthe region, as it may vary widely, as it does in bottled water.Efforts should be made to meet the recommended intake ofcalcium, especially in hypocaloric diets, through anadequate choice of foods. Consider circumstances thatmay interfere with calcium absorption (malabsorption syn-drome, foods rich in phytohaemaglutinins, drugs, and soon). Potassium needs can usually be met by increasingdietary vegetables and fruits.

There is no consistent evidence of the risks or benefits ofmoderate chronic coffee consumption (2 cups/day).

Alcohol consumption is directly related to BP levels andthe prevalence of hypertension in different populations.There is also evidence that alcohol abuse blunts the effect ofantihypertensive drugs. Alcohol consumption by diabetic

patients should be discouraged, or a maximum of 30 g/dayallowed to men and 15 g/day to women.

Meals should be distributed as three or four meals, andone or two snacks during the day should be preferred,depending on the patient’s schedule and pharmacologicaltreatment of diabetes mellitus. Ethnical preferences andsocioeconomic status should also be considered.

Physical activityA sedentary lifestyle and the lack of physical activity arestrong predictors of cardiovascular mortality, independentof BP and other risk factors. The intensity of the recom-mended exercise should be individualized according to theclinical condition. When the planned activity does notexceed 60% of maximum oxygen consumption (VO2

max, e.g. walking), a clinical examination will suffice.When a more intense activity is planned, a more extensivescreening of possible diabetic complications should becarried out. Special attention must be paid to silent(or compensated at rest) heart disease, proliferative retin-opathy, incipient nephropathy, peripheral vascular disease,peripheral and autonomic neuropathy and osteoarthrop-athy, especially of the lower limbs, which may cause feetlesions. An individual, three-times-a-week-programmemust be prepared, including moderate intensity recrea-tional-like aerobic activity (equivalent to 3–5 Metabolicequivalents) in the form of sports or domestic exercise,lasting from 20–60min per session, preceded by a previous5 to 10-min warm-up, and followed by 5 to 10-min relaxa-tion. The patient must be instructed on the appropriateclothing to prevent feet lesions, such as cotton socks andsport shoes. Self-monitoring of blood glucose before andafter exercise may help preventing hypoglycemia and allowthe patient to verify the beneficial effects of exercise onglycaemic control [86–88]. Intense exercise is contraindi-cated for patients with active proliferative retinopathy,clinical nephropathy or neuropathy.

Pharmacological treatmentThe benefits of reducing BP in diabetic patients have beenclearly shown by the results of the Hypertension OptimalTreatment (HOT) [89] and United Kingdom Prospec-tive Diabetes Study (UKPDS) [90] studies among others[91–95]. Diabetic patients may require more intense treat-ment to achieve the same BP levels as nondiabetic individ-uals. Thus, almost every diabetic patient will need, inaddition to nonpharmacological measures, a combinationtreatment to achieve BP treatment goals, as earlier aspossible.

The target SBP to be achieved to guarantee an optimalprotection from cardiovascular outcomes to hypertensivepatients with diabetes has been an issue of intense debate,recently. Although a number of guidelines in the past[1,2,69,70] had recommended a lower target of less than130/80 mmHg in diabetic patients (and generally in high-risk patients) than in low–moderate risk hypertensivepatients (<140/90 mmHg), a recent reappraisal of the avail-able evidence [71,96] has demonstrated that no one of therandomized trials of antihypertensive treatment in diabeticpatients with hypertension has ever achieved mean SBP




values below 130mmHg, and the recent Action to ControlCardiovascular Risk in Diabetes (ACCORD) [97] trial hasshown no further reduction of cardiovascular outcomes buta higher incidence of adverse effects in the diabetic patientsrandomized to achieve an SBP of less than 120 as comparedwith an SBP of less than 140 mmHg (average values actuallyachieved 119 and 133 mmHg). A number of meta-analyses[98,99] have attempted to correlate cardiovascular out-comes with achieved BPs and have found no further benefitor worsening of cardiovascular outcome incidence at lowerBP, with the possible exception of the incidence of stroke[99].

In summary, it appears that in hypertensive patients withdiabetes, an SBP target of less than 140 mmHg can berecommended as in nondiabetic hypertensive individuals.However, values just above 130 mmHg (as achieved inACCORD [97] and ADVANCE [100]) appear safe and maybe more effective in reducing or preventing microalbumi-nuria [100]. As to target DBP, the results of the HOT [89] andUKPDS [90] studies indicate that values between 80 and85mmHg are beneficial.

As to patients with diabetic nephropathy, previousguidelines have commonly recommended BP targets130/80 and less than 120/75mmHg in case of proteinuria.A recent review [101] has shown that these recommen-dations are not supported by trial results and are only basedon findings from long-term, nonrandomized follow-up oftrials. It appears prudent, therefore, to recommend thesame BP targets to diabetic patients with and withoutnephropathy.

Five classes of antihypertensive agents [diuretics,beta-blockers, angiotensin-converting enzyme inhibitors(ACEIs), angiotensin receptor blockers (ARBs) and calciumchannel blockers (CCBs)] have been used in randomizedtrials that have shown that BP lowering significantlyreduces cardiovascular, cerebrovascular and renal out-comes in hypertensive patients with diabetes as well aswithout diabetes [102], and therefore, all of them can bechosen in patients with hypertension and type 2 diabetes.However, when selecting to initiate treatment with mono-therapy, drugs blocking the renin–angiotensin–aldoster-one system (RAAS), ACEIs or ARBs, should be preferredbecause of their greater antiproteinuric effect. ARBs arecommonly better tolerated, and this is a relevant issue inpatients with hypertension in whom adherence is essential.As a general rule, a long-acting agent providing BPreduction over the 24 h should be indicated in order touse possibly a single daily administration. Recently, regu-latory agencies [US Food and Drug Administration (FDA)and European Medicines Agency (EMEA)] have approvedramipril as ACEI and telmisartan as ARB for patients withhigh cardiovascular risk (i.e. hypertensive patients withtype 2 diabetes) on the basis of Heart Outcomes PreventionEvaluation (HOPE) [94] and Ongoing Telmisartan Aloneand in Combination with Ramipril Global Endpoint(ONTARGET) [103] trials.

In most patients with type 2 diabetes and hypertension,the desirable BP target cannot be achieved with mono-therapy and treatment must include two or more agents. Ifbefore treatment SBP/DBP is far from target values, it isrecommended to initiate with a two-drug combination, a

fixed combination of an ACEI or ARB with a dihydropyr-idine CCB or a diuretic. The Avoiding Cardiovascular Eventsthrough Combination Therapy in Patients Living withSystolic Hypertension (ACCOMPLISH) trial [104] has showngreater benefits with an ACEI/CCB rather than an ACE/diuretic combination, but these interesting data need to beconfirmed. When three drugs are needed, an ACEI or ARBalong with a CCB as well as either a thiazide or indapamidediuretic should be used. In patients with a GFR less than30ml/min, thiazide diuretics should be replaced by a loopdiuretic (such as furosemide) at appropriate doses. Theassociation of ACEI and ARB, as well that of an ACEI or ARBwith a renin inhibitor (aliskiren) have a greater antiprotei-nuric effect, but the association of ACEI and ARB failed toshow greater outcome reduction in ONTARGET [103] andactually had more adverse effects, and ALTITUDE [105], atrial in diabetic patients testing the association of aliskirenwith an ACEI or ARB, was prematurely interrupted for moreadverse effects of the association. Therefore, the associationof two different drugs interfering with the renin–angioten-sin system, at full doses, is at present discouraged.

Diuretics and beta-blockers, particularly in association,increase insulin resistance and may facilitate onset of dia-betes in predisposed individuals, and therefore this associ-ation should possibly be avoided in hypertensive patientswith prediabetes or the metabolic syndrome. Vasodilatingbeta-blockers, such as nebivolol and carvedilol, appear notto impair insulin sensitivity, and nebivolol has recently beenshown not to worsen glucose tolerance even when addedto a thiazide diuretic [106]. Therefore, vasodilating beta-blockers should be preferred in those conditions in whichthere are compelling reasons for administering a betablocker (ischaemic heart disease, heart failure, tachyar-rhythmia, and so on).

In patients with renal and/or cardiac dysfunction, cardiacfunction may be improved by the administration ofmineralocorticoid receptor antagonists (spironolactone,eplerenone), which have been shown to be effective inresistant hypertension. However, serum levels of potassiumand GFR should be closely monitored in patients with renaldisease using a RAAS inhibitor and an aldosterone anta-gonist.

Alpha blockers have been shown to improve insulinresistance and might be used as an additional agent inhypertensive patients with type 2 diabetes, not achievingBP target, although they are not recommended as mono-therapy except in hypertensive patients with prostatichypertrophy. Table 8 indicates antihypertensive agents tobe preferred for drug management of hypertensive patientswith type 2 diabetes and special conditions.

SPECIAL POPULATIONSHypertension and diabetes in Afro-LatinAmericansPeople in Latin America belong to different ethnicities [107].The prevalence of the various ethnicities in each LatinAmerican country is characterized by a mixture of races,ethnicities and cultures as in no other continent.

Despite the large number of black people in LatinAmerica, there is no epidemiologic study on the prevalence




of hypertension and diabetes in this population, and nostudies have investigated dietary intake, physical activity,body build associated with hypertension and diabetes in asufficiently large sample of this racial group using consist-ent methodologies. Most of the information results fromstudies conducted in the USA including black people whohad migrated from Latin America and the Caribbean to USA[108,109] or USA-born youth of Latin and Caribbean origin[32].

Thus, the first recommendation of the Latin AmericanConsensus is to encourage academic and governmentalorganizations in Latin America to support epidemiological,clinical and therapeutic research in African-Latin Americanpeople to investigate whether the results of USA studiesalso apply to African descendants living in Latin America.Up to now, the only available study assesses the import-ance of arterial hypertension in a rural district of blackpeople living in the province of Esmeraldas in Ecuador[110], where 4284 of the 8876 adults living in the area werescreened. Hypertension was found in 1542 (36%) of them,only four (0.3%) of whom were well controlled by treat-ment. In the 2.5 years of follow-up, CVD was the majorcause of death in the adult population. Furthermore, fourof five of the individuals who died by CVD had a history ofhypertension. Thus, the prevalence of uncontrolled hyper-tension in this study was much higher than that reported inthe USA studies.

Until a suitable number of data are collected in LatinAmerica, the Consensus recommends adopting the recentrecommendations of the International Society of Hyperten-sion in Blacks [111]. According to the latter documentamong black people, there is a clear geographical differ-ence in the prevalence of hypertension: 14% in WesternAfrica, 26% in Caribbean and 33% in USA. These differencesare tentatively attributed to differences in diet and lifestyle.In USA, black women are more sedentary, have a highcaloric intake and are more obese already in the preadultperiod [112,113]. Genetic and environmental factors, suchas low socioeconomic status, high dietary sodium and/orlow dietary potassium intake, and low birth weight becauseof maternal malnutrition, have been associated with poorrenal development and lower number of nephrons,predisposing to arterial hypertension and early kidneydysfunction [114,115].

The cardiorenal complications related to arterial hyper-tension and type 2 diabetes (stroke, left ventricular hyper-trophy, cardiac failure, chronic or end-stage renal failure)occur more often in black than in white people. Hyper-tensive blacks have 4–20 times higher risk of progressing to

dialysis than whites with similar BP levels, and mortality inAfrican-American men is three times higher (49%) than innon-Hispanic whites in USA (16%), and two and a half timeshigher in black women (37%) than in non-Hispanic (14%)white women [116].

The choice between antihypertensive monotherapy anddrug combination depends on the presence or absence ofcomorbidities, and the specific efficacy of the drugs to beused. Comparative studies have shown that black hyper-tensive patients have a better response to thiazide diuretics(hydrochlorothiazide or chlorthalidone) and CCBs than toACE inhibitors, angiotensin II receptor blockers or beta-blockers [117,118]. The best control is always obtained ifsodium intake is reduced. Furthermore, blacks are moreprone to present angioneurotic oedema in response toACEIs than white people [119]. Therefore, in blacks, mono-therapy should be based on either a diuretic or a CCB, andwhen combination therapy is decided, this should include aCCB and/or a diuretic along with a RAAS blocker, pref-erably an ARB.

Hypertension and diabetes in the AndespopulationThe Latin American populations living in the Andes Moun-tains share similar characteristics and historic patterns ofcolonization as native Indians living at lower altitudes,being mostly Amerindians or mestizos. Those people livingat a high altitude (over 3000 m above sea level) represent aspecial group in whom the prevalence of hypertension anddiabetes is scarcely known. A population-based study [120]included 1878 adults living in the Peruvian Andes. Theprevalence of hypertension was 15.7% [95% confidenceinterval (CI), 14.0–17.4), did not differ by sex andincreased steeply with age, particularly in women. Aware-ness, treatment and control rates were 47.9, 39.5, and 14%,respectively. DBP increased until age 50 years and reacheda plateau thereafter, whereas mean arterial pressure con-tinued to increase with age even after age 50. The pre-dominant type of hypertension was systolic-diastolic(41.7%; 95% CI, 35.1–48.5) or isolated diastolic. Isolatedsystolic hypertension accounted for only 29.3% of cases(95% CI, 23.9–35.4) and was responsible for a minority ofcases in all age groups before age 70. That diastolic hyper-tension is predominant in the Andes Mountains over3000 m above sea level has recently been confirmed inanother study [121], which has found that more than 50% ofthis population was unaware of their hypertensive con-dition. This study also showed that the prevalence of

TABLE 8. Drug use recommendations for hypertensive patients with diabetes type 2 and special conditions

Coronary heart disease and/or left ventricular dysfunction ACEI/ARBs, beta-blockers, aldosterone antagonists

Isolated systolic hypertension in the elderly Calcium channel blockers, diuretics, ARBs

Angina pectoris Calcium channel blockers, beta-blockers often in association

Chronic renal disease ACEI or ARBs, especially in presence of microalbuminuria or overt proteinuria

Peripheral artery disease Calcium channel blockers

Patients with atrial fibrillation Beta-blockers, ARBs, ACEIs, nondihydropyridine calcium channel blockers

Left ventricular hypertrophy ACEI, ARBs, CCBs

Benign prostatic hypertrophy Alpha blockers

ACEI, angiotensin-converting enzyme inhibitor; ARBs, angiotensin receptor blockers; CCB, calcium channel blocker.




hypertension was similar in the coast, sierra and jungleareas of Peru [120,121].

Hypertension and diabetes in the elderlyThe PanAmerican Health Organization (PAHO)/WHOreport on demographic data from Latin America [122] hasshown that people older than 60 years represent 14% of thetotal population in Argentina, 10% in Brazil, 13% in Chile,8% in Colombia, 9% in Ecuador, 7% in Paraguay, 8% in Peru,18% in Uruguay, 8% in Venezuela and 8% in Mexico.

Elderly people, defined as individuals older than65 years, have an increased risk of arterial hypertension,specially isolated systolic hypertension [123,124], implyingan additional cardiovascular risk because pulse pressurehigher than 65mmHg is associated with greater stiffness ofthe large arteries wall and increased cardiovascular morbid-ity and mortality [124]. ABPM during 24 h is considered auseful tool to optimize the clinical evaluation of elderlyhypertensive patients [125,126], in whom abnormal noctur-nal BP falls and morning BP surges have been claimed to beassociated with cerebrovascular disease [127,128], althoughthese findings have been recently disputed [129].

All trials that have demonstrated the benefits of BPlowering in the elderly have aimed at an SBP target of lessthan 150 mmHg [96], and this should be considered as theevidence-based target for elderly hypertensive patients,but in the otherwise healthy elderly a target similar tothat recommended for younger hypertensive patients($140 mmHg) can be considered. There is also evidenceof benefits in reducing SBP to less than 150 mmHg inhypertensive patients aged 80 years and older [130]. Frailor complicated individuals should be treated with particularattention not to worsen their general health conditions.

In the elderly individuals, the pharmacological treatmentmust be initiated gradually to guarantee good tolerabilityand quality of life. Sexuality (sexual dysfunction), sleep andfunctional status must be considered in the clinical evalu-ation of this population [10].

Various clinical trials have demonstrated the benefits ofreducing isolated systolic hypertension [131–133], by usingdiuretics or CCBs. Other trials in elderly hypertensivepatients, a number of whom with isolated systolic hyper-tension, have also used ACE inhibitors and angiotensinreceptor inhibitors, and these classes of drugs can alsobe used in the elderly, both as monotherapy and in com-bination.

In those patients with associated cardiovascular risk orcomorbidities, the drug of choice must be selected inaccordance with the concomitant illness, as inidcated inTable 8. Long-lasting acting drugs are preferable in face of abetter compliance and a sustained 24-h antihypertensiveaction.

THE ROLEOF ENVIRONMENTANDEPIGENETICS IN METABOLICSYNDROME, HYPERTENSIONANDDIABETES IN LATINAMERICAThe increasing incidence of metabolic syndrome, diabetestype 2 and CVDs in Latin America seems to be associated to

environmental influences and ethnic characteristics [134].This raises the possibility that genetic predispositionassociated with particular ethnic groups might interactwith environmental factors to explain different incidenceof disease. There has been considerable interest in thespecial influence of in-utero and early-life environmentalexposure. This is represented in the Developmental Ori-gins of Disease hypothesis that emphasizes the criticalperiods in early life during which body structure andfunction can be set for life. More recently, the early effectsof environment have been conceived in terms of epi-genetics.

Epigenetics is the science that explains the variationof gene expression in response to changes in environ-mental conditions. This term includes any processthat alters gene activity without changing the DNAsequences and leads to rapid but reversible modificationsof DNA (e.g. methylation) or chromatin that can betransmitted to daughter cells. DNA methylation of aregulatory region for a specific gene can inhibit geneexpression. Chromatin is the nuclear complex consistingof DNA wrapped around histone proteins that can bemodified by acetylation to influence gene expression[135].

The mechanisms that control epigenetic processes arenot yet completely understood, but it is clear that heritableDNA variation might alter the sensitivity to certain environ-mental triggers or change the nature of the epigeneticresponses to a given exposure. In the Latin Americancontext, the question is whether regional and ethnic vari-ation in epigenetic processes or simply differences in theenvironmental exposures explain diversity in the metabolicsyndrome.

It is well known that in Latin America, the maternal andchildhood undernutrition has been an important problemthat not yet has been resolved in an important percentage ofthe poor populations [136]. In Latin America, a high preva-lence of arterial hypertension has been found in children,adolescents and adults with nutritional stunting [137–144].One study in Brazil [137] that investigated arterial pressurein a random sample of adolescent slum residents withstunting (10–16 years, n! 56) showed an elevated per-centage of these individuals to have an arterial pressureabove the 90th and 95th percentiles, adjusted for height,and were at a risk for hypertension. Considering the groupof patients as a whole, the prevalence of diastolic arterialhypertension was 21% (95% CI, 10–32-%). The prevalenceof cases with a systolic or diastolic arterial pressure abovethe 90th percentile was 51% (95% CI, 37–65). Anotherstudy done in the northeast of Brazil [138] with 416 adults(18–60 years), also slum residents, showed that arterialhypertension was prevalent in 28.5% of the population(women, 38.5%; men, 18.4%). The SBP and DBP increasedaccording to the reduction in stature, and hypertension wasmore prevalent in women who were obese and short (50%)than in those who were obese but not short [odds ratio(OR), 1.98; 95% CI, 1.22–2.96]. Recently, another survey[139] investigated whether the health conditions of motherswho had a short stature were different from those withoutstunting or that of their offspring. A short maternal staturewas independently associated with obesity, abdominal




obesity and increased arterial pressure. Furthermore, shortmaternal stature was associated with a low birth weightand stunting in children. In Colombia, it was demon-strated that children 11 years old with a medium BMI of21 kg/m2, the higher tertile, presented an increaseof 10 mmHg in relation to children with a medium BMIof 15 kg/m2, the lower tertile [140]. Also in Brazil, Francoet al. [141] reported changes in the sympathoadrenal andrenin–angiotensin systems in children small for theirgestational age. They investigated the plasma levels ofACE, angiotensin and catecholamines in 8 to 13-year-oldchildren to determine correlations between the plasmalevels and both birth weight and BP. Circulating nor-adrenaline levels were significantly elevated in smallgestational age girls compared with girls born with aweight appropriate for their gestational age. In addition,angiotensin II and ACE activity were higher in smallgestational age boys. There was a significant associationbetween the circulating levels of both angiotensin II andACE activity and SBP. Another study in Brazil [142]showed that ACE activity is increased, together with anincrease in systolic and diastolic pressure in children withstunting independent of birth weight.

Although in Latin America the prevalence of type 2diabetes mellitus in individuals who were undernour-ished in early life is not known, it is known that poorcountries with an accelerated process of urbanization areparticularly vulnerable and have been experiencing aconsiderable increase in diabetes prevalence [143]. Del-eterious changes have been reported in glucose metab-olism in Mexican children suffering from undernutritionin infancy. The study examined the effects of undernu-trition in the first year of life on glucose tolerance andplasma insulin and found that early undernutrition in theextra-uterine period, independent of the birth weight,was associated with hyperinsulinemia and a reducedsensitivity to insulin, which worsened as BMI increasedin adult life [143].

So, it is interesting to speculate that the increased ratesof hypertension, metabolic syndrome and type 2 diabetesmellitus, observed in Latin America, could be the result ofthe discrepancy between the nutritional environmentduring foetal and early life and the adult environment.This discrepancy causes a mismatch between the foetalprogramming of the subject and the adult circumstancescreated by the imposition of new lifestyles [144]. Theconflict between the earlier programming and the laterpresence of abdominal obesity may have produced ahigher sensitivity of this population to develop a stateof low-degree inflammation, insulin resistance and, con-sequently, an epidemic of hypertension, metabolic syn-drome and diabetes. The relative roles played by geneticand environmental factors and the interaction betweenthe two are still the subjects of great debate and meritfurther research.

The recommendation of the Latin American Consensus isto stimulate academia to develop research aimed to estab-lish the epigenetic mechanisms explaining the relationshipbetween maternal malnutrition, early growth restrictionand the later occurrence of abdominal obesity and CVDin Latin America.

ACKNOWLEDGEMENTSParticipants on the ConsensusChairs: Patricio Lopez-Jaramillo (Colombia); RamiroSanchez (Argentina).

Coordinators: Agustin J. Ramirez (Argentina); HelenaSchmid (Brazil).

Advisors: Alberto Zanchetti (Italy); Stephen Harrap(Australia).

Participants: Jose L. Accini (Colombia); Sergio Alvernia(Colombia); Edgar Arcos (Colombia); Myrian Ayala(Paraguay); Mario Bendersky (Argentina); Fabio Bolıvar(Colombia); Rodrigo Botero (Colombia); Alfonso Bryce(Peru); Jannes Buelvas (Colombia); Carlos Calderon(Colombia); Juan Mauricio Cardenas (Colombia); MariaE. Casanova (Colombia); Gilberto Castillo (Colombia);Leonardo Cobos (Chile); Carlos Cure (Colombia); MargaritaDıaz (Uruguay); Yan C. Duarte (Ecuador); John Duperly(Colombia); Luıs Echeverrıa (Colombia); Tatiana Espinosa(Colombia); Jhon Feliciano (Colombia); Milton C. Foss(Brazil); Peggy Freire (Ecuador); Henry Garcıa (Colombia);Luıs H. Garcıa (Colombia); Santiago Garcıa (Ecuador);Diego Gomez-Arbelaez (Colombia); Erick Hernandez(Colombia); Juan D. Higuera (Colombia); Diego Huertas(Colombia); Sergio Jaramillo (Colombia); Isabel Jauregui(Colombia); Fernando Lanas (Chile); Joffre Lara (Ecuador);Fernando Lizcano (Colombia); Livia Machado (Venezuela);Helard Manrique (Peru); Fernando Manzur (Colombia);Alvaro Marquez (Colombia); Gustavo Marquez (Colombia);Javier Martınez (Colombia); Luz X. Martınez (Colombia);Felix Medina (Peru); Roberto Medina (Mexico); EnriqueMelgarejo (Colombia); Alonso Merchan (Colombia); HaroldMiranda (Colombia); Dora I. Molina (Colombia); SolonNavarrete (Colombia); Gustavo Parra (Colombia); Jose Z.Parra Carrillo (Mexico); Miguel Pasquel (Ecuador); Jesus A.Pena (Colombia); Ernesto Penaherrera (Ecuador); MaritzaPerez (Colombia); Belkis Pineda (Colombia); Daniel Pis-korz (Argentina); Carlos Ponte (Colombia); Hernan Prat(Chile); Juan J. Rey (Colombia); Jesus Rodriguez (Colom-bia); Patricia Rodriguez (Colombia); Gregorio Sanchez(Colombia); Ivan D. Sierra (Colombia); Arıstides Sotomayor(Colombia); Isaac Synay (Argentina); Juan C. Uribe (Colom-bia); Manuel Urina (Colombia); Ricardo Vargas (Chile);Boris Vesga (Colombia); Carlos Velandia-Carrillo (Colom-bia); Raul Villar (Chile); Eduardo Villarreal (Colombia);Alejandro Yenes (Chile).

Conflicts of interestThere are no conflicts of interest.

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Consenso latino-americano de hipertensão em pacientes com diabetes tipo 2 e síndrome metabólica

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